7 - Uncertainty in Medicine: A Matter of Time
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What does the opening segment reveal about the link between time and uncertainty in medicine?
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This is The Nocturnist, Uncertainty in Medicine. Today, we're looking at time.
The 14-year-old girl lay pale and lifeless on the stretcher. A plastic breathing tube jutted out of her mouth, and at the head of the bed, the intern squeezed oxygen into her lungs. The medics said they found her down in the bathroom without a pulse. The resident pushed on her chest, doing compressions. Her ribs crunched with a nauseating sound of broken bones grinding against each other. When I asked the parents what happened, her dad stared at me glassy-eyed, mute from shock. while the mother screamed incoherently so loudly I almost couldn't hear my own thoughts. The medic handed me a can of silver spray paint. He said the patient had locked herself in the bathroom 30 minutes ago. Dad broke down the door, finding her with a spray can in one hand and a paper bag in the other.
She collapsed to the ground instantly in cardiac arrest. The diagnosis was immediately clear. A sudden sniffing death. The result of sniffing, huffing, bagging, chroming, or otherwise misusing inhalants. In contrast to most cases of cardiac arrest in the ER, the uncertainty wasn't in the cause, but in the treatment. Give epinephrine or don't give epinephrine? Inhalants affect the heart. In the myocardium, cells are supposed to be synchronized, conducting nerve impulses and squeezing to pump the blood in an organized fashion. Inhalant exposure causes disorganization. This is the first insult. If a second insult occurs, the primed myocardium might suddenly conduct abnormal impulses in a disorganized fashion, resulting in sudden death.
What's the source of the second insult? An adrenaline or epinephrine spike. And how does that occur? Well, one way is terror or fear causing a fight-or-flight response, for example, being caught by a parent or by the police. The standard of care for treatment in cardiac arrest? Epinephrine. The second insult in sudden sniffing death? Epinephrine. I faced a choice to withhold a potentially heart-restarting drug or to give more of the exact same substance that put her into cardiac arrest. Did I want to withhold the drug? No. Not just that, but not giving epi could be considered legally and ethically wrong. On the other hand, did I want to expose her to more? Also, no. Uncertainty is common in medicine. It's an everyday occurrence, and normally I discuss the options with the patient or the parents, explain the risks and benefits, then engage in shared decision-making.
With this patient, there was no time for discussion, and the parents weren't in a position to help. Standing at the bedside, I ran the risks and benefits on a continuous loop through my brain, hoping desperately to come up with the right answer. I considered pitfalls, possibilities, pros and cons. Each time I arrived at the same answer, I didn't know what to do. At the end of the two minutes, the nurse hauled up a syringe of epinephrine waiting for me to say yes. My heart raced, my breathing sounded loud, my palms were wet, but despite this, I had to pretend to be calm and collected.
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Chapters
5 chapters
1
What does the opening segment reveal about the link between time and uncertainty in medicine?
0:00–6:03
2
How did the ER toxicologist decide whether to give epinephrine to a teenage patient who inhaled a spray?
6:03–14:33
3
Why did the toxicologist ultimately choose a beta‑blocker instead of epinephrine, and what was the outcome?
14:33–24:02
4
What does Trisha’s chronic ankle‑pain story illustrate about long‑term medical uncertainty and doctor‑patient communication?
24:02–30:23
5
How does a rheumatologist manage patients when diagnoses are ambiguous and may take years to confirm?
30:23–32:59